Healthcare Provider Details

I. General information

NPI: 1043201734
Provider Name (Legal Business Name): THERESE DEIERLEIN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 E 67TH ST SUITE #4F
NEW YORK NY
10065-6119
US

IV. Provider business mailing address

250 FORT LEE RD STE #C, AUDIOLOGY 2000 INC
TEANECK NJ
07666-3904
US

V. Phone/Fax

Practice location:
  • Phone: 212-628-2710
  • Fax: 212-628-3580
Mailing address:
  • Phone: 212-628-2710
  • Fax: 212-628-3580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number0010601
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number41YA00028200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: